Gregg Nelson1, Eleftheria Kalogera2, Sean C Dowdy3. 1. Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada. 2. Division of Gynecologic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA. 3. Division of Gynecologic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA. Electronic address: dowdy.sean@mayo.edu.
Abstract
OBJECTIVE: Many commonplace perioperative practices are lacking in scientific evidence and may interfere with the goal of optimizing patient recovery. Individual components of perioperative care have therefore been scrutinized, resulting in the creation of so-called "enhanced recovery" pathways (ERP), with the goal of hastening surgical recovery through attenuation of the stress response. In this review we examine the evidence for ERP in gynecologic oncology using data from our specialty and general surgery. METHODS: We performed a systematic literature search on ERP in gynecologic oncology in June 2014 using PubMed/MEDLINE, EMBASE, and The Cochrane Library. All study types were included. References were hand reviewed to ensure completeness. The Enhanced Recovery After Surgery (ERAS) Society was contacted to identify any unpublished protocols. RESULTS: Seven investigations were identified that examined the role of ERP in gynecologic oncology. Common interventions included allowing oral intake of fluids up to 2 hours before induction of anesthesia, solids up to 6 hours before anesthesia, carbohydrate supplementation, intra- and postoperative euvolemia, aggressive nausea/vomiting prophylaxis, and oral nutrition and ambulation the day of surgery. In addition, bowel preparations, the NPO after midnight rule, nasogastric tubes, and intravenous opioids were discontinued. While no randomized data are available in gynecologic oncology, significant improvements in patient satisfaction, length of stay (up to 4 days), and cost (up to $7600 in savings per patient) were observed in ERP cohorts compared to historical controls. Morbidity, mortality, and readmission rates were no different between groups. CONCLUSION: Enhanced recovery is a safe perioperative management strategy for patients undergoing surgery for gynecologic malignancies, reduces length of stay and cost, and is considered standard of care at a growing number of institutions. Our specialty would benefit from a formalized ERP such as ERAS which audits compliance to protocol care elements to optimize patient outcomes and value.
OBJECTIVE: Many commonplace perioperative practices are lacking in scientific evidence and may interfere with the goal of optimizing patient recovery. Individual components of perioperative care have therefore been scrutinized, resulting in the creation of so-called "enhanced recovery" pathways (ERP), with the goal of hastening surgical recovery through attenuation of the stress response. In this review we examine the evidence for ERP in gynecologic oncology using data from our specialty and general surgery. METHODS: We performed a systematic literature search on ERP in gynecologic oncology in June 2014 using PubMed/MEDLINE, EMBASE, and The Cochrane Library. All study types were included. References were hand reviewed to ensure completeness. The Enhanced Recovery After Surgery (ERAS) Society was contacted to identify any unpublished protocols. RESULTS: Seven investigations were identified that examined the role of ERP in gynecologic oncology. Common interventions included allowing oral intake of fluids up to 2 hours before induction of anesthesia, solids up to 6 hours before anesthesia, carbohydrate supplementation, intra- and postoperative euvolemia, aggressive nausea/vomiting prophylaxis, and oral nutrition and ambulation the day of surgery. In addition, bowel preparations, the NPO after midnight rule, nasogastric tubes, and intravenous opioids were discontinued. While no randomized data are available in gynecologic oncology, significant improvements in patient satisfaction, length of stay (up to 4 days), and cost (up to $7600 in savings per patient) were observed in ERP cohorts compared to historical controls. Morbidity, mortality, and readmission rates were no different between groups. CONCLUSION: Enhanced recovery is a safe perioperative management strategy for patients undergoing surgery for gynecologic malignancies, reduces length of stay and cost, and is considered standard of care at a growing number of institutions. Our specialty would benefit from a formalized ERP such as ERAS which audits compliance to protocol care elements to optimize patient outcomes and value.
Authors: Ester Miralpeix; Alpa M Nick; Larissa A Meyer; Juan Cata; Javier Lasala; Gabriel E Mena; Vijaya Gottumukkala; Maria Iniesta-Donate; Gloria Salvo; Pedro T Ramirez Journal: Gynecol Oncol Date: 2016-03-09 Impact factor: 5.482
Authors: Larissa A Meyer; Javier Lasala; Maria D Iniesta; Alpa M Nick; Mark F Munsell; Qiuling Shi; Xin Shelley Wang; Katherine E Cain; Karen H Lu; Pedro T Ramirez Journal: Obstet Gynecol Date: 2018-08 Impact factor: 7.661
Authors: Ana Sofia Ore; Matthew A Shear; Fong W Liu; John L Dalrymple; Christopher S Awtrey; Leslie Garrett; Hannah Stack-Dunnbier; Michele R Hacker; Katharine McKinley Esselen Journal: Int J Gynecol Cancer Date: 2019-11-25 Impact factor: 3.437
Authors: Tanvi V Joshi; Shaina F Bruce; Rod Grim; Tommy Buchanan; Sudeshna Chatterjee-Paer; Elizabeth R Burton; Joel I Sorosky; Mark S Shahin; Mitchell I Edelson Journal: Gynecol Oncol Rep Date: 2021-04-30